Literature Review

The Most Effective Way of Delivering a Train-the-Trainers

Program: A Systematic Review

JENNIFER PEARCE, BSC; MALA K. MANN, BECCERTLIS, MIINFSC, MCLIP; CARYL JONES, BSC, MSC;
SUSANNE VAN BUSCHBACH, BSC, MSC; MIRANDA OLFF, BSC, MSC, PHD; JONATHAN I. BISSON, BM, FRCPSYCH,
DIP CLIN PSYCHOTHERAPY DM

Introduction: Previous literature has shown that multifaceted, interactive interventions may be the most effective
way to train health and social care professionals. A Train-the-Trainer (TTT) model could incorporate all these
components. We conducted a systematic review to determine the overall effectiveness and optimal delivery of TTT
programs.
Methods: We searched 15 databases. Reference lists and online resources were also screened. Studies with an
objective follow-up measure collected over 1 week after the intervention were included. The intervention had to be
based on a TTT model for health and social care professionals.
Results: Eighteen studies met the inclusion criteria. TTT interventions varied greatly, ranging from didactic pre-
sentations to group discussions and role-plays. The heterogeneity of the studies and limited data prevented meta-
analysis. A narrative review found that the TTT programs in 13 studies helped to increase knowledge, improve
clinical behavior, or produce better patient outcomes. One study showed no effect. Three studies showed possible
effect and one study showed that a CD-ROM training method was more effective than a TTT training method in
improving participants’ knowledge. Ratings of the studies’ methodologies suggested moderate risk of bias, which
limits interpretation of the results.
Discussion: There is evidence that using a blended learning approach to deliver TTT programs—combining
different techniques such as interactive, multifaceted methods and accompanying learning materials—can help to
effectively disseminate and implement guidelines and curricula to health and social care professionals. However,
further research is needed to determine the optimum “blend” of techniques.
Key Words: Train-the-Trainer, TTT, cascade training, effectiveness, guideline dissemination, systematic review

Disclosures: The authors report none. Introduction

Ms. Pearce: Research Assistant, Department of Psychological Medicine,
Cardiff University; Ms. Mann: Information Specialist, Support Unit for Re-
search Evidence, Cardiff University; Ms. Jones: Research Assistant, Depart-
ment of Psychological Medicine, Cardiff University; Dr. van Buschbach:
Researcher/Psychologist, Academic Medical Center, Department of Psy-
chiatry, Center for Anxiety Disorders, University of Amsterdam; Dr. Olff:
Professor in Psychotraumatology, Head Center for Psychological Trauma,
Department of Psychiatry, Academic Medical Center, University of Amster-
dam; Dr. Bisson: Director of Research and Development, Cardiff University
School of Medicine and Cardiff and Vale University Health Board.
Correspondence: Professor Jonathan I. Bisson, 2nd Floor TB2, Univer-
sity Hospital of Wales, Heath Park, Cardiff, Wales, CF14 4XW; e-mail:
BissonJI@cf.ac.uk.

C 2012 The Alliance for Continuing Education in the Health Professions, the
Society for Academic Continuing Medical Education, and the Council on
Continuing Medical Education, Association for Hospital Medical Education.
r Published online in Wiley Online Library (wileyonlinelibrary.com).
DOI: 10.1002/chp.21148
Health and social care curricula, guidelines, legislation and
policies are constantly being published or revised; the need
to have an effective method of disseminating this informa-
tion to health and social care professionals is crucial. There
appears to be some evidence that multifaceted, interactive
interventions, possibly with the inclusion of some form of
prompt/reminder system are more effective than passive, di-
dactic education strategies in disseminating information to
health and social care professionals.1–6 However, despite this
growing evidence, conclusions are made difficult because it
has been suggested that no firm conclusions can be drawn
from the existing literature on how best to disseminate such
information due to methodological and reporting flaws.2–3
The authors were tasked with designing a training pro-
gram for the EU-funded European Network for Trau-
matic Stress—Training and Practice (TENTS-TP) project7

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 32(3):215–226, 2012

 Pearce et al.
to train health and social care professionals in the TENTS
curriculum. These professionals would then need to cascade
this training to staff in their respective organizations. A Train-
the-Trainers (TTT) educational model was proposed as a po-
tentially effective and cost-efficient way of doing this, as
it could combine the various interactive and multifaceted
techniques that have received some empirical support.1–6
Train-the-Trainer refers to a program or a course where indi-
viduals in a specific field receive training in a given subject
and instruction on how to train, monitor, and supervise other
individuals in the approach.8–9
An initial scoping search to determine the quantity and
quality of research in this field revealed that there was a
limited but, for the purposes of this review, sufficient body
of research on the effectiveness of TTT programs. It also
showed that no systematic reviews of the literature had been
conducted, leaving open questions such as how effective are
TTT programs, how frequently are they used, how have they
been designed and evaluated, and what has been their impact.
Therefore, the aim of this review was to address 2 primary
questions: (1) Are TTT programs an effective method of
training health and social care professionals? and (2) What
delivery mechanisms yield the most effective results?
Method
The methods used in this review followed the recommended
methodology for conducting systematic reviews.10
Information Sources
The databases Applied Social Sciences Index and Abstracts
(ASSIA), Cumulative Index to Nursing and Allied Health
Literature (CINAHL), Cochrane Library, Excerpta Med-
ica Database (EMBASE), Education Resources Information
Center (ERIC), Health Management Information Consor-
tium (HMIC), MEDLARS Online (MEDLINE), Medline
in Process, System for Information on Grey Literature in
Europe (OpenSigle), Psychological Information Database
(Psycinfo), Scopus, Social Care Online, Social Services Ab-
stracts, Sociological Abstracts, Web of Knowledge, and Pub-
lished International Literature on Traumatic Stress (PILOTS)
were searched from inception through June 15, 2011. The
search strategy detailed in FIGURE 1 was used to search
MEDLINE and modified, where necessary, to search the
other databases. Reference lists of included studies were
scrutinized for additional papers. Furthermore, we contacted
experts and carried out a web search to identify any additional
papers. One person conducted the initial search for literature
and the initial exclusion stage. Two people then reviewed the
remaining 530 titles, abstracts, and full texts for eligibility
and extracted the relevant information.
216 JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012
DOI: 10.1002/chp
1. evaluat*.mp.
2. effect*.mp.
3. assess*.mp.
4. apprais*.mp.
5. Evaluation Studies as Topic/
6. Program Evaluation/
7. or/1–6
8. ((Train or teach or educate or instruct or coach or guide or tutor) adj4
(trainer* or teacher* or educator* or instructor*)).mp.
9. ((Training or teaching or educating or instructing or coaching or guiding or
tutoring) adj4 (trainer* or teacher* or educator* or instructor* or coach or
coaches or guide or guides or tutor or tutors)).mp.
10. ((Trained or taught or educated or instructed or coached or guided or
tutored) adj4 (trainer* or teacher* or educator* or instructor* or coach or
coaches or guide or guides or tutor or tutors)).mp.
11. "coach-the-coach".mp.
12. "tutor-the-tutor".mp.
13. (TTT adj3 train*).mp.
14. or/8–13
15. 7 and 14
FIGURE 1. MEDLINE Search Strategy
Note: MP stands for multipurpose. It will search several fields at once,
including the term in the Title, Original Title, Abstract, Subject Heading,
Name of Substance, and Registry Word fields.
Inclusion Criteria
Intervention. The intervention had to be based on a TTT
model; that is, the participants being trained in the inter-
vention must have to go on to train others in the specified
topic/guidance following their training. Topics of interest in-
cluded any health or social care field (eg, HIV/AIDS, breast-
feeding, mental health, counseling). There were no restric-
tions on duration, format, or content of the TTT model.
Target Population. The participants in the TTT program must
have been qualified health and social care professionals who,
after receiving training, were expected to be capable of deliv-
ering training to other health care professionals. Specifically,
we were interested in the health and social care professionals
who attended the TTT programs, including nurses, psychol-
ogists, social workers, and the like.
Study Design. Randomized controlled trials (RCTs), well-
designed quasi-experimental studies, controlled before-and-
after studies (CBAs), and interrupted time series analyses
(ITS) were included, subject to the presence of a control
 Train-the-Trainers Programs: Systematic Review
group. There also must have been a follow-up outcomes
measure administered more than 1 week after the intervention
was delivered (eg, participants’ clinical behavior 3 months
after the training program).
The comparison conditions to the TTT groups could in-
clude different training methods (eg, the intervention is de-
livered through lectures or e-learning).
Outcome. The outcomes must have been related to the effec-
tiveness of the training program and include some objective
measure of change. Outcomes could relate to the primary re-
cipients of the TTT intervention or the secondary recipients
(the health and social care professionals who subsequently re-
ceived training from the primary recipients). For either group
of recipients, outcomes could be at the level of knowledge,
clinical behavior, or patient outcomes.11 It was agreed a pri-
ori that outcomes should include objective measures relating
to participants or patients/clients as either would be likely to
represent a valid measure for assessing the effectiveness of a
TTT program.
Publication. Published and unpublished studies were eligi-
ble for inclusion.
Exclusion Criteria
Study Design. Studies relying on anecdotal evidence derived
from individual opinions and studies without control groups
were excluded.
Language. Non-English-language studies were excluded
due to financial constraints.
Data Extraction
Study data were collected using a data extraction form, based
on a form used in a previous systematic review, which was
a modified version of the EPOC Data Abstraction form.12
The details extracted from the studies were study design;
population characteristics; characteristics of the intervention,
including the content, format, setting and duration; a de-
scription of the primary outcome measure; description of the
training methods used; details on participants’ recruitment;
who delivered the training; what course materials were used;
what implementation issues there were; and the effective-
ness of the intervention. These categories were chosen to
provide a detailed breakdown of the delivery style and struc-
ture of each TTT program and make it possible to examine
commonalities between the studies. We also extracted quan-
titative information (means and standard deviations) for each
primary outcome reported for the intervention and control
groups.
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012
Data Synthesis
The primary outcome measure was the effectiveness of the
training intervention, either through knowledge tests, clini-
cal behavior, or patient reports. Meta-analyses of the differ-
ent primary outcome measures were to be performed if the
papers included sufficient data to do this. If this were not pos-
sible, a narrative synthesis approach would be used to explore
the effectiveness of the TTT programs included. Addition-
ally, information on the different components of the TTT
programs was extracted (eg, interactive and didactic tech-
niques, learning materials, duration of programs) in order to
examine the association between blends of techniques and
efficacy.
Risk of Bias
The risk of bias for all included studies was assessed using
the 6 specific domain-based evaluation criteria set out in the
Cochrane risk of bias form.10 These were sequence genera-
tion, allocation concealment, blinding, incomplete outcome
data, selective outcome reporting, and other sources of bias.
Two reviewers independently assessed each study for risk of
bias. Any conflicts were discussed with a third reviewer.
Results
Study Selection
The search yielded 23 904 references (see FIGURE 2). Re-
moval of duplicates gave a total of 16,917. An additional
5 941 titles were identified via a Web search. A total of 22 630
papers were excluded after reviewing the titles and abstracts.
Full text for 228 papers was obtained because they appeared
relevant or there was insufficient information to make a judg-
ment to exclude them from the abstracts and titles alone. Two
hundred nine of these papers were excluded.
Eighteen studies reported in 19 articles were included in
our review. The 2 articles by Carlo et al13–14 reported data
for the same population across multiple outcome measures.
For the purposes of our review, we refer to both papers as 1
study.
Data Synthesis
Due to the heterogeneity of the studies and limited data avail-
able within the papers, it was not possible to perform meta-
analyses. We were also unable to calculate effect sizes despite
our attempts to contact authors of the studies. Unfortunately,
most authors no longer had this information or were not
contactable. Therefore, a narrative synthesis approach was
used.
217
DOI: 10.1002/chp
 Pearce et al.

No. of records identified through No. of additional records identified

database searching = 23 904 through other sources = 5 941

No. of records after duplicates removed = 16,917

No. of records screened = 22 858 No. of records excluded = 22 630

No. of full-text articles assessed No. of full-text articles excluded = 209:

for eligibility = 228 Not experimental or did not have a
control group (132)
Did not concern TTT programs (44)
Not from peer-reviewed journals (13)
Not looking at health and social care
professionals (13)
Not reported in English (3)
Objective measurement collected less
than 1 week following program (2)
Inability to obtain paper (2)

No. of studies included in qualitative analysis = 19

FIGURE 2. Systematic Review Flowchart: Main Phases and Number of Papers Identified at Each Stage (flowchart of search process based on the PRISMA
template)

Study Characteristics included a third group. Sanddal17 compared the effectiveness

Study Design. Three study designs were employed; 8 ran-
domized controlled trials,8,13–20 6 controlled before-and-
after studies,21–26 and 4 controlled clinical trials.9,27–29 The
topic, content, materials, setting, duration, and primary out-
come measures of the TTT programs varied greatly, which
made direct comparisons problematic (for full details see
TABLE 1 and the Supporting Information for this article).
Methods of Training. The training methods em-
ployed varied considerably: 7 reported including
case studies and scenarios,8–9,19,23,26–27,29 4 didactic
presentations,19,22,24,27 2 video presentations,24,29 3 Pow-
erPoint slides,9,23,28 5 group discussions,9,19,24–25,29 9
interactive components,8–9,13–15,19,22,26–27 7 practical
demonstrations and exercises,8,13–14,21,26–28 4 role-
plays,19,24,27,29 1 motivational and attitudinal change
elements,21 1 individual feedback on strengths and
weaknesses,22 1 problem-based learning,16 5 preparation
to deliver future training workshops,19–20,23,28–29 and 1
questions-and-general-comments session.24
Effectiveness of Training
Training Versus No Training. All studies evaluated a training
group versus a nonintervention (control) group. Three17,19–20
of a TTT intervention in training staff in emergency medical
services with a CD-ROM intervention and a control group.
Tziraki et al19 compared the effectiveness of a TTT interven-
tion in the adoption of cancer-prevention nutrition-related ac-
tivities to a manual-only group and a control group. Martino
et al20 compared the effectiveness of expert-led and TTT
strategies to a self-study approach to teaching motivational
interviewing skills.
Outcome Measures
Clinical Behavior. Eight of the studies used measures of
clinical behavior to assess the effectiveness of the TTT
program,8–9,15–16,18–20,26 2 did not measure preintervention
behavior.15,19 Six8,15–16,19–20,26 showed that a TTT interven-
tion significantly improved participants’ subsequent clinical
behavior.
One study9 measured the effect of implementing a new
treatment guideline on prescribing behavior through the use
of a TTT program. It was difficult to identify a primary
outcome for the purpose of this review because the study
measured prescribing practices for 6 main infections. The
percentage of cases in which the first-line antibiotic was
chosen on the basis of diagnosis showed a significant increase
for sinusitis, acute bronchitis, and urinary tract infection but

218 JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012

DOI: 10.1002/chp
 TABLE 1. Included Studies Assessing the Effectiveness of TTT Programs

Material on Outcome Training Vs. Effective, Neutral,

Paper Details Country Methods of Training Topic Durationb the Course Measures No Training or Negativec Risk of Bias

Brambila et al Guatemala • Practical Improving access to More than 3 days None mentioned Patient outcome Yes Effective Medium
21
(2005) demonstrations and services
exercises
• Motivational and
attitudinal change
elements
Byrne et al United States • Didactic Mental health More than 3 days None mentioned Knowledge scores Yes Effective High
22 a
(2010) • Interactive
• Individual feedback
on strengths and
weaknesses
Carlo et al Democratic • Interactive Infant death 3 days Tools/ equipment Patient outcome Yes No effect Medium
(2010)13–14 Republic of • Practical
Congo, demonstrations and
Guatemala, exercises
India, Pakistan,
and Zambia
Train-the-Trainers Programs: Systematic Review

Cattaneo et al Italy • Case studies and Breast-feeding More than 3 days Folder of Patient outcome Yes Effective Medium
23
(2001) scenarios information
• PowerPoint slides
• Session on preparing
trainers to deliver
future training
workshop

(Continued)

DOI: 10.1002/chp
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012
219
 TABLE 1. Continued

220
Material on Outcome Training Vs. Effective, Neutral,
b
Paper Details Country Methods of Training Topic Duration the Course Measures No Training or Negativec Risk of Bias

Davies-Adetugbo Nigeria • Case studies and Breast-feeding 2 days None mentioned Patient outcome Yes Effective Medium

DOI: 10.1002/chp
et al (1997)27 scenarios
• Didactic
presentations
• Interactivea
• Practical
demonstrations and
exercises
• Role-plays

Ezedinachi et al Nigeria • Didactic HIV/AIDS 2 days None mentioned Knowledge/attitudeYes Possible effect but Medium
(2002)24 presentations scores could not contact
• Video presentations authors to obtain
• Role-plays more data.
Pearce et al.

• Group discussions
• Questions and
general comments
session
Fairall et al South Africa • Interactivea Tuberculosis More than 3 Tools/ equipment Clinical behavior Yes Effective Medium
15

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012

(2005) detection days
Lynch et al United States • PowerPoint slides Back injury 1 day Handouts Knowledge scores Yes Effective Medium
(2000)28 • Practical
demonstrations and
exercises
• Session on preparing
trainers to deliver
future training
workshop

(Continued)
 TABLE 1. Continued

Methods of Material on Outcome Training Vs. Effective, Neutral,

Paper Details Country Training Topic Durationb the Course Measures No Training or Negativec Risk of Bias

Martino et al United States • Session on Motivational More than 3 Manual Clinical behavior Yes Effective Medium
20
(2010) preparing trainers interviewing days
to deliver future
training workshop
Meyer et al South Africa • Problem-based Better prescribing More than 3 Manual Clinical behavior Yes Effective Medium
16
(2001) days
Moon et al Canada • Case studies and Infant death 1 day None mentioned Clinical behavior Yes Effective Medium
8
(2008) scenarios
• Interactivea
• Practical
demonstrations
and exercises
Ramberg et al Sweden • Group discussions Mental health More than 3 None mentioned Knowledge scores Yes Effective High
(2004)25 days
Rautakorpi et al Finland • Case studies and Better prescribing More than 3 None mentioned Clinical behavior Yes Possible effect. Medium
(2006) (9) scenarios days Difficult to
• PowerPoint slides identify a main
• Interactivea primary
• Group discussions outcome.
Train-the-Trainers Programs: Systematic Review

Sanddal et al United States • None mentioned Pediatric training Unknown None mentioned Knowledge scores TTT, CD-ROM, Effective but Medium
17
(2004) and control CD-ROM
group training was
more effective
than TTT.
Schwartzberg United States • Case studies and Elderly care Less than 1 Folder of Clinical behavior Yes Effective Medium
et al (1997)26 scenarios day information
• Interactivea
• Practical
demonstrations

DOI: 10.1002/chp
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012
and exercises

221
(Continued)
 222
TABLE 1. Continued

Material on Outcome Training Vs. Effective, Neutral,

b
Paper Details Country Methods of Training Topic Duration the Course Measures No Training or Negativec Risk of Bias

DOI: 10.1002/chp
Shrestha et al Nepal • None mentioned Better prescribing More than None mentioned Clinical behavior Yes There is an effect but no Medium
(2006)18 3 days information on
significance.
Tziraki et al. United States • Case studies and Cancer prevention Less than Manual Clinical behavior TTT, manual only, Effective Medium
19
(2000) scenarios 1 day and control group
• Didactic
presentations
• Interactivea
• Role-plays
• Group discussions
• Session on
preparing trainers
to deliver future
Pearce et al.

training workshop
Wu et al China • Case studies and HIV/AIDS Unknown Manual Knowledge scores Yes Effective Medium
(2002)29 scenarios
• Video
presentations

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012

• Role-plays
• Group discussions
• Session on
preparing trainers
to deliver future
training workshop

a
Interactive refers to an active educational process that involves getting participants engaged in exercises and discussions.
b
These categories of duration were chosen because most TTT programs were delivered between 1 and 4 days. This helped distinguish between the shorter and longer programs.
c
Information extracted on the primary outcome measure in included papers was used to determine whether a TTT program was as effective, neutral, or negative in changing knowledge scores,
clinical behavior or patient outcomes.
 Train-the-Trainers Programs: Systematic Review
not for 3 other main infections. Therefore, the TTT program
was judged to have induced some improvement in clinical
behavior.
The primary outcome examining the effect of a TTT pro-
gram on prescription behavior for respiratory conditions18
showed an increase in the drugs prescribed from an Essential
Drugs List after training. However, the authors did not con-
duct a statistical analysis of this data, so we were unable to
conclude if the change was statistically significant.
Knowledge Tests. Six studies assessed effectiveness through
knowledge tests.17,22,24–25,28–29 All 6 included a pre-
and postintervention measure, and 4 found that a TTT
model was effective in improving the knowledge of
participants.22,25,28–29
One study17 showed that the use of a CD-ROM to train
participants in prehospital emergency medical services for
children induced greater improvements in performance than
the TTT intervention.
One study24 looked at how a TTT program could im-
prove health workers’ skills and confidence in dealing with
patients with HIV disease. A significant change in health
workers’ skills and confidence in dealing with patients with
HIV disease after the TTT intervention was reported. We
were unable to contact the authors to extract specific data on
primary outcomes.
Patient Outcomes. Four studies measured patient out-
comes in order to assess the effectiveness of the TTT
program,13–14,21,23,27 2 did not take a preintervention
measure.13–14,27 Three studies showed a significant improve-
ment in patient outcomes in the TTT group.21,23,27 One
study13–14 showed that there was no effect of the TTT train-
ing on the rates of neonatal deaths 7 days after birth.
Risk of Bias Within Studies
Ratings of the studies’ methodologies suggested risk of bias
for all included studies. Two of the 18 papers were judged as
having a high risk of bias22,25 because the allocation to con-
trol and intervention groups was not randomized. In Byrne
et al’s study,22 there was a significant difference between
the 2 groups’ professions (37% nurses in the expert trained
group compared with 78% in the novice trained group). This
could potentially have affected the training and delivery of
the TTT intervention. No studies were judged to have a low
risk of bias, primarily because only 1 study15 had published a
protocol. This meant that it was not possible to judge whether
outcomes had been selectively reported. Our conclusions are,
therefore, limited by the bias of included studies.
Despite the methodological flaws, the majority of the stud-
ies used appropriate study designs and methods for statistical
inference. For example, the statistical method used was ap-
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012
propriate to the study design and population and most studies
had reasonable sample sizes.
Discussion
Eighteen papers were included in this review and, despite
significant heterogeneity compromising comparison, pro-
vided support for TTT programs as an effective way to
disseminate knowledge and information to health and so-
cial care professionals. Thirteen of the 18 studies showed
that TTT programs significantly helped to improve clini-
cal behavior,8,15–16,19–20,26 increase knowledge,22,25,28–29 or
resulted in better patient outcomes.21,23,27 Another 3 studies
showed a possible effect,9,18,24 1 study13–14 no effect, and an-
other found that CD-ROM training was more effective than
TTT training.17 Data contained within the papers and the
systematic review authors’ interpretation of other informa-
tion contained within the papers were used to determine the
strength of effect of each study.
Eleven of the positive studies used interactive compo-
nents to deliver the training.8,15,19,21–23,25–29 This supports
previous research in the field, which suggests that interactive
training methods can be more effective than passive, didac-
tic style training.1–6 Two of the studies where no definitive
conclusions of effectiveness could be made9,24 and the study
that found the TTT program to have no effect13–14 also used
interactive components to deliver the training. This suggests
that interactivity alone is not necessarily the key variable
in achieving a positive outcome when delivering a training
program.
The majority of the included studies delivered the train-
ing over more than a 3-day period,9,15–16,18,20–23,25 but the
studies that delivered the training in 3 days or less were simi-
larly effective in increasing knowledge or improving clinical
behavior and patient outcomes.8,19,26–28
The effect of including accompanying learning materi-
als in TTT programs is unclear. All the studies that pro-
vided handouts, manuals, or folders of information were
effective.16,19–20,23,26,28–29 This suggests that combining the
TTT program with learning materials may improve the ef-
fect of the TTT program. This notion is also supported by the
findings in Tziraki et al19 and Martino et al’s20 studies, which
showed that the TTT program and manual group was more ef-
fective than a manual only or self-study group. Other studies
have supported this finding.30–31 However, a number of the
included studies in which the TTT program was found to be
effective did not provide information on accompanying learn-
ing materials. Additionally, no studies have compared a TTT
program with additional learning materials to a TTT program
without, allowing no definitive conclusions to be made.
Eight randomized controlled trials (RCTs) were in-
cluded in this review. Two studies that used an RCT
methodology13–14,17 found no effect or that an alternative
223
DOI: 10.1002/chp
 Pearce et al.
training method was more effective than a TTT program. This
is balanced by five other RCTs,8,15–16,19–20 which showed
superiority for a TTT program in training professionals.
Although the majority of the included studies in this re-
view found that a TTT program was effective, 1 study com-
paring a TTT intervention with a CD-ROM training method
found that the latter was more effective in improving partic-
ipants’ knowledge.17 Support for the use of computer-aided
training has been found in other studies.32–33 Martino and
colleagues’ study20 also found that an expert-led training
group was as effective as the TTT training group. These
studies suggest that a TTT program approach is not the only
training method that can be used to effectively train health
and social professionals. Further research is needed to clarify
which methods should be employed and when.
This study has several limitations. First, there was a great
deal of heterogeneity, both clinical in terms of the conditions
focused on and methodological when it came to the eval-
uation of the TTT programs. It is important to note that 3
distinct types of primary outcome measure were used: clin-
ical behavior, participant knowledge, and patient outcomes.
Improvements were seen in a similar proportion of the stud-
ies that considered the different measures and therefore all
18 studies were considered together in the discussion. It is,
however, conceivable that different components impact dif-
ferentially on the effectiveness of TTT programs, depending
on which type of outcome is measured. This and the other
aspects that contribute to the heterogeneity within the in-
cluded studies meant that it was difficult to compare the
effectiveness of the TTT programs across studies. It was,
therefore, not possible to determine what specifically made
each intervention effective. Second, outcomes at the level of
primary and secondary recipients of the training were not
distinguished. It would be reasonable to expect to find dif-
ferences in degree of impact on these different audiences.
Third, only studies published in peer-reviewed journals were
included, introducing publication bias. Fourth, this review
relied on English language studies alone, due to absence of
funding for translation costs. This limits the generalizability
of the findings. The diversity of topics and countries in which
the studies were conducted does, however, temper this limi-
tation. Fifth, none of the studies were judged to have a low
risk of bias.
This review is the first systematic review of the effective-
ness of TTT programs and therefore represents a substantial
contribution to the knowledge base in this area. We con-
ducted a scoping search using the Cochrane method10 before
commencing this review to determine the quantity and qual-
ity of research in this field. This helped to refine and inform
the aims and design of our review. This review employed a
rigorous, systematic approach to searching, identifying and
appraising papers, and was undertaken by a team with con-
siderable experience doing systematic reviews. The methods
224 JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012
DOI: 10.1002/chp
used followed the recommended methodology for conduct-
ing systematic reviews,10 although the need to rely upon a
narrative review process is a limitation.
The evidence from this review and previous literature1–6
provides support for the use of interactive, multifaceted TTT
programs to disseminate and implement guidelines and cur-
ricula to health and social care professionals from diverse
cultures working in different clinical areas. Previous litera-
ture has highlighted the benefits of using a “blended learning”
approach to train professionals.34–36 A blended learning ap-
proach is described as combining “multiple delivery media
that are designed to complement each other and promote
learning and application-learned behaviour.”37 It can be con-
cluded that a combination of techniques, including interac-
tive components and learning materials, should be blended to
create the most effective training course for health and social
care professionals and that traditional, didactic-style training
should only be used as part of a blended learning approach.
It is not possible, however, to identify the exact balance and
blend of techniques that should be used in order to develop
the most effective TTT program.
Three studies in this review8–9,15 identified a potential
long-term problem with the TTT model. They found that it
was often difficult to ensure the continuing implementation of
the training programs due to high staff turnover and retention
of staff after they had been trained. Long-term sustainability
and staff commitment need to be considered when developing
TTT programs.
Program developers should give careful consideration to
delivery method, program content, and issues of staff com-
mitment and retention when developing training programs in
order to optimize the approach to fit the specific target audi-
ence and setting. The finding that a CD-ROM training method
is more effective than a TTT program17 in 1 study suggests
that there may be other, perhaps more cost-efficient train-
ing methods, to improve clinical behavior, knowledge and
patient outcomes. Program developers need to consider this
alongside the apparent utility of incorporating face-to-face
training techniques, such as role-play and group discussions,
when designing training programs.
Despite the limitations of the currently available evidence,
this review has shown that TTT programs have the potential
to effectively disseminate information to health and social
care professionals. It appears that using a blended learning
approach, combining different techniques and materials, is
likely to achieve the best results. Further research is needed to
determine the best “blend” of techniques and how they impact
on participant and patient/client facing outcome measures. A
randomized controlled trial that examines different combina-
tions of techniques used in TTT models would help to better
determine the most effective blend. Additionally, future work
should consider interactivity in more detail.1,2,4 Conducting
future studies of TTT in a manner that allows publication
 Train-the-Trainers Programs: Systematic Review
of manuscripts that follow the CONSORT guidelines38 for
the reporting of randomized controlled trials would facilitate
future reviews in this area. Until definitive evidence emerges,
robust methods of achieving consensus, such as the Delphi
approach7 should be considered to determine the optimal
composition of TTT programs.
Data Sharing
For additional information on all data, please contact the
author responsible for correspondence.
Funding
A grant from the European Union funded this study.
References
1. Davis D, Taylor-Vaisey A. Translating guidelines into practice: a sys-
tematic review of theoretic concepts, practical experience, and re-
search evidence in the adoption of clinical practice guidelines. CMAJ.
1997;157(4):408–416.
2. Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical
guideline implementation strategies: a synthesis of systematic review
findings. J Eval Clin Pract. 2008;14(5):888–897.
3. Grimshaw J, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al.
Changing provider behavior: an overview of systematic reviews of in-
terventions. Med Care. 2001;39(8 (suppl 2)):II-2–II-45.
4. Onion C, Bartzokas C. Changing attitudes to infection management
in primary care: a controlled trial of active versus passive guideline
implementation strategies. Fam Pract. 1998;15(2):99–104.
5. Grol R, Grimshaw J. From best evidence to best practice:
effective implementation of change in patients’ care. Lancet.
2003;362(9391):1225–1230.
6. Bero L, Grilli R, Grimshaw J, Harvey E, Oxman A, Thomson M. Clos-
ing the gap between research and practice: an overview of systematic
reviews of interventions to promote implementation of research findings
by health care professionals. BMJ. 1998;317:465–468.
7. Pearce J, Jones C, Morrison S, et al. Using a Delphi process to develop
an effective Train-the-Trainers programme to train health and social
care professionals throughout Europe. J Traum Stress. In press.
8. Moon RY, Calabrese T, Aird L. Reducing the risk of sudden infant death
syndrome in child care and changing provider practices: lessons learned
from a demonstration project. Pediatrics. 2008;122(4):788–798.
9. Rautakorpi UM, Huikko S, Honkanen P, et al. The antimicrobial treat-
ment strategies (MIKSTRA) program: a 5-year follow-up of infection-
specific antibiotic use in primary health care and the effect of implemen-
tation of treatment guidelines. Clin Infect Dis. 2006 ;42(9):1221–1230.
10. Higgins J, Green S. Cochrane handbook for systematic reviews of in-
terventions Version 5.0.2 [Updated September 2009].
11. Moore DE Jr, Green JS, Gallis HA. Achieving desired results and
improved outcomes: integrating planning and assessment throughout
learning activities. J Contin Educ Health Prof. 2009;29(1):1–15.
12. Cochrane Effective Practice and Organisation of Care Review
Group. EPOC resources for review authors [Web site]. Available
at: http://epoc.cochrane.org/epoc-author-resources. Accessed March 1,
2010.
JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012
13. Carlo W, Goudar S, Jehan I, Chomba E, Tshefu A, Garces A. High
mortality rates for very low birth weight infants in developing countries
despite training. Pediatrics. 2010;126(5):1072–1080.
14. Carlo WA, Goudar SS, Jehan I, Chomba E, Garces A, Parida S, et al.
Newborn-care training and perinatal mortality in developing countries.
N Engl J Med. 2010 Feb18;362(7):614–623.
15. Fairall L, Zwarenstein M, Bateman E, et al. Effect of educational out-
reach to nurses on tuberculosis case detection and primary care of
respiratory illness: pragmatic cluster randomised controlled trial. BMJ.
2005;331(7519):750–754.
16. Meyer JC, Summers RS, Moller H. Randomized, controlled trial
of prescribing training in a South African Province. Med Educ.
2001;35(9):833–840.
17. Sanddal ND, Sanddal TL, Pullum JD, et al. A randomized, prospective,
multisite comparison of pediatric prehospital training methods. Pediatr
Emerg Care. 2004;20(2):94–100.
18. Shrestha N, Samir K, Baltussen R, Kafle K, Bishai D, Niessen L. Prac-
tical approach to lung health in Nepal: better prescribing and reduction
of cost. Trop Med Int Health. 2006;11(5):765–772.
19. Tziraki C, Graubard BI, Manley M, Kosary C, Moler JE, Edwards BK.
Effect of training on adoption of cancer prevention nutrition-related
activities by primary care practices: results of a randomized, controlled
study. J Gen Intern Med. 2000;15(3):155–162.
20. Martino S, Ball S, Nich C, Canning-Ball M, Rounsaville B, Car-
roll K. Teaching community program clinicians motivational in-
terviewing using expert and Train-the-Trainer strategies. Addiction.
2011;106(2):428–441.
21. Brambila C, Lopez F, Garcia-Colindres J, Donis MV. Improving access
to services and interactions with clients in Guatemala: the value of dis-
tance learning. J Fam Plann Reprod Health Care. 2005 Apr;31(2):128–
131.
22. Byrne MK, Willis A, Deane FP, Hawkins B, Quinn R. Training in-
patient mental health staff how to enhance patient engagement with
medications: Medication Alliance training and dissemination out-
comes in a large US mental health hospital. J Eval Clin Pract. 2010
February;16(1):114–120.
23. Cattaneo A, Buzzetti R. Effect on rates of breast feeding of training
for the baby friendly hospital initiative. BMJ. 2001;323(7325):1358–
1362.
24. Ezedinachi E, Ross M, Meremiku M, et al. The impact of an interven-
tion to change health workers’ HIV/AIDS attitudes and knowledge in
Nigeria: a controlled trial. Public Health. 2002;116(2):106–112.
25. Ramberg I-L, Wasserman D. Benefits of implementing an academic
training of trainers program to promote knowledge and clarity in work
with psychiatric suicidal patients. Arch Suicide Res. 2004;8(4):331–
343.
26. Schwartzberg JG, Guttman R. Effect of training on physician attitudes
and practices in home and community care of the elderly. Arch Fam
Med. 1997 Sep–Oct;6(5):439–444.
27. Davies-Adetugbo AA, Adebawa HA. The Ife South Breastfeeding
Project: training community health extension workers to promote and
manage breastfeeding in rural communities. B World Health Organ.
1997;75(4):323–332.
28. Lynch RM, Freund A. Short-term efficacy of back injury intervention
project for patient care providers at one hospital. Am Ind Hyg Assoc J.
2000;61(2):290–294.
29. Wu Z, Detels R, Ji G, Xu C, Rou K, Ding H, et al. Diffusion of HIV/AIDS
knowledge, positive attitudes, and behaviors through training of health
professionals in China. AIDS Educ Prev. 2002;14(5):379–390.
30. Sholomskas D, Syracuse-Siewert G, Rounsaville B, Ball S, Nuro K,
Carroll K. We don’t train in vain: a dissemination trial of three strategies
of training clinicians in cognitive–behavioral therapy. J Consult Clin
Psych. 2005;73(1):106–115.
225
DOI: 10.1002/chp
 Pearce et al.
31. Sholomskas D, Carroll K. One small step for manuals: computer-
assisted training in twelve-step facilitation. J Stud Alcohol.
2006;67(6):939–945.
32. Amesse L, Callendar E, Pfaff-Amesse T, Duke J, Herbert W. Evalua-
tion of computer-aided strategies for teaching medical students prenatal
ultrasound diagnostic skills. Med Educ Online. 2008;13:1–6.
33. Rosser J, Hermana B, Risucci D, Murayama M, Rosser L, Merrell R.
Effectiveness of a CD-ROM multimedia tutorial in transferring cog-
nitive knowledge essential for laparoscopic skill training. Am J Surg.
2000;179(4):320–324.
34. Pereira J, Pleguezuelos E, Merı́ A, Molina-Ros A, Molina-Tomás
MC, Masdeu C. Effectiveness of using blended learning strategies for
teaching and learning human anatomy. Med Educ. 2007;41(2):189–
195.
35. Jonas D, Burns B. The transition to blended e-learning. Changing the
focus of educational delivery in children’s pain management. Nurse
Educ Pract. 2010;10(1):1–7.
36. Cucciare MA, Weingardt KR, Villafranca S. Using blended learning
to implement evidence-based psychotherapies. Clin Psychol-Sci Pr.
2008;15(4):299–307.
226 JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—32(3), 2012
DOI: 10.1002/chp
37. Singh H. Building effective blended learning programs. Educ Tech.
2003;43:51–54.
38. Schulz KF, Altman DG, Moher D, for the CONSORT Group. CON-
SORT 2010 Statement: updated guidelines for reporting parallel group
randomised trials. BMJ. 2010;340:c332.
Supporting Information
Additional supporting information may be found in the online
version of this article:
TABLE S1: Numerical Data Assessing the Effectiveness
of TTT Programmes for Included Studies
As a service to our authors and readers, this journal pro-
vides supporting information supplied by the authors. Such
materials are peer reviewed and may be reorganized for on-
line delivery, but are not copy edited or typeset. Technical
support issues arising from supporting information (other
than missing files) should be addressed to the authors.